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WARNING: A "Second Prescriber Addendum" authored by a second, concurring
Hematology-Oncology prescriber is required to validate this plan.
A "Nursing Quality Assurance Addendum" is required to initiate the plan.
See Addendum Requirements at end of note for further information.
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CHEMOTHERAPY ORDERS NOTE
Hematology-Oncology/Medical Sevice VA Ann Arbor Healthcare System
Regimen: Carbo+Taxol, AUC 7 and 175 mg/M2
Citation: Kosmidis P, et al. 1997 Ann Oncol. 8(7):697-9
PMID: 9296226 Enter PMID at http://www.pubmed.gov for abstract.
Code: carbo-tax7_175
Version: AA3 Expires: 06/01/05 Authority: Heme-Onc Sec., Med. Svc.
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// Paired slashes ("//") indicate lines with format instruction and guidance.
// Colons (":") mark points where entries are required.
// Prescriber must place triple hash marks ("###") at the left margin of any
// line containing any modifications (other than colon-marked entries).
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PATIENT DATA
Patient Name (last, first):
Last 4:
Diagnosis:
Cycle #:
Consent Date:
Gender:
Age(y):
Ht(in):
Wt(lb):
BSA(M2):
Serum Creatinine(mg/dl):
Estimated CCr:
Male:Est. CCr = (140 - Age) x Wt /2.2lb/kg /72 /SCr
Female:Est. CCr = (140 - Age) x Wt /2.2lb/kg /72 /SCr x 0.85
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HOLD CONTINGENCIES - Hold chemotherapy if:
ANC < 1,500 OR Platelets < 100,000 OR Hgb < 9
PREPARATION
Education: Assure adequate patient knowledge of the regimen,
it's toxicities and their management.
Hydration: Encourage generous oral hydration
PREMEDICATION
Standard:
Ondansetron (Zofran) 16-24 mg PO 30 minutes pre-chemotherapy
Prochlorperazine (Compazine) 10mg PO/IV 30 minutes pre-chemo
and Q6 hours PRN
Special:
30 to 60 min. prior to paclitaxel give:
Cimetidine 300 mg I.V. Piggyback
Benadryl 50 mg I.V. Push
Dexamethazone 20 mg I.V. Push
(unless pt took 20 mg p.o. 12 and 6 hrs prior to chemo)
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ANTINEOPLASTIC DRUGS
//A numbered line followed by the drug name begins the entry for each drug
//Dose calculation must be presented explicitly in a vertical format
//Use a decimal fraction in "mod" term to express reductions or increases.
//Use a leading zero before decimal fractions. Avoid decimals in final doses.
//Greater than signs (">>>...") mark the calculated dose per administration.
//Formulation, Route, Schedule, and special instructions conclude each entry.
General Dose Modification Comments : Presented on next line?
1. Paclitaxel (Taxol) mod:
x dose (mg/M2):
x BSA(M2):
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> = mg/day =
Give in 500 ml D5W IV over 3 hours, Day 1 only.
2. Carboplatin Target AUC:
x (Est.CCr + 25):
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> = mg/day =
Give in 100 ml D5W IV over 30 minutes, Day 1 only.
Schedule: Day 1 of this cycle is (date):
Cycle Length (days):
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POST-THERAPY MEDICATIONS
Filgrastim (Neupogen, G-CSF)
daily dose (micrograms subcut.):
day of cycle to start: 4
days to continue: 10
Antiemetics will be ordered per standard protocol for:
Level 4, Moderately High, emetogenicity.
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* WARNING - ADDENDUM REQUIREMENTS *
* This Chemotherapy Orders Note was authored and signed by the principal
prescribing physician as a draft statement of the intended treatment plan.
It is a non-actionable draft in the absence of a "Second Prescriber Addendum"
by a Hematology-Oncology physician stating agreement with the plan.
However, with the addition of such an addendum, the note becomes a complete
and final specification of the current chemotherapy plan for this patient.
* A "Nursing Quality Assurance Addendum" must be attached to
document quality checks and to initiate execution of the plan.
The nurse notifies Pharmacy of the plan at the time this addendum is added.
* In the event that the note must be voided prior to execution,
an "Invalidation Addendum" will be attached by a Hematology-Oncology
physician and will state the reason for voiding the orders. A newly authored
Chemotherapy Orders Note must be authored if a revised plan is required.
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